September EMS Rounds

1. Rounds 9/17/2015
State update
Toxicology Update: synthetic
Cannabinoids , Marijuana, and
powdered caffeine
Epinephrine and Cardiac Arrests
Marijuana and Synthetic
Cannabinoids

2. Welcome back
• VA and transports….don’t
• Patient preferences and destinations …TBD

3. Toxicology Update
• Powdered caffeine: unregulated and marketed
as a dietary supplement . Two young men died
this past year from overdoses. One teaspoon
is equivalent to 28 cups of coffee.

4. Synthetic Cannabinoids
• Marijuana…active ingredient is THC. There are
now many synthetic cannabinoids [SC] available .
They first appeared in 2008 and they have
proliferated. Sold as liquid for e cigarettes ,
dissolved in energy drinks , sold as “legal
alternatives to marijuana” , they are dangerous.
Over 26 synthetic cannabinoids are considered
schedule 1 drugs [highly illegal] . There have been
over 20 deaths in the past 18 months in the US.
90% of these deaths came after smoking the
drug.

5. Cannabinoids continued
• There are other effects beside deaths…delirium,
seizures , psychosis , hallucinations and coma.
Thee are no available antidotes.
• These drugs are not detected by our toxic
screens!
• Names of these drugs include Crazy Clown, 10X,
ABD-Pinaca, AB-Chiminaca , etc.
• Over the past 6 months there have been 1200 ED
visits and 17 deaths in 12 states [southeast] .

6. Marijuana
• It is estimated that 160 million people used
marijuana at least once last year. This is 4% of the
world’s population!
• The active component of marijuana is THC. The
content of THC has tripled over the past 50 years.
• There is clear evidence that marijuana use may
be addictive. 1% of cannabis users become
dependent on it and will withdraw when they are
abstinent. Over 2/3 of users stop its use. It is not
terribly addictive.

7. More marijuana [please? ]
• Three side effects will be noted. Cannabis use
increases the likelihood of psychosis by 1.5-2
fold. You are one and one half to twice as
likely to become psychotic if you smoke
marijuana.
• Marijuana use decreases testosterone levels
and lowers sperm counts . It will decrease
fertility in men.

8. Cannabinoid Hyperemesis Syndrome
• This is a condition of recurrent episodes of
vomiting and colicky abdominal pain occurring
in patients who use marijuana regularly.
• The clue to this syndrome is that the patients
get relief from hot showers. The vomiting is
resistant to medications [Zofran, etc], but hot
showers or the use of capsaicin [red hot chili
peppers] topically applied will relieve the
vomiting and abdominal pain .

9. Cardiac Arrest Update
• In November we should have the 2015 AHA Guidelines.
• Therapeutic Hypothermia is question with 2 new
papers from Europe and Australia shedding doubt on
its utility
• We must increase the rate of Bystander CPR. We need
to get our schools to make CPR training mandatory and
we need to get the public to understand how time
sensitive life is. In a large study from Denmark [ 29,000
patients] over a 10 year span . Bystander CPR tripled
their success for CPR. No surprise….

10. Epinephrine and Cardiac Arrests
• There has been a lot of question about the
utility of epinephrine in cardiac arrests. Three
recent papers should help guide our efforts.
Our resuscitation rates are 40 %. This is
markedly better than most communities.
Epinephrine is a part of our protocol and we
should continue to use it given our success.
But what does the recent literature and
scientific data reveal ?

11. Two recent papers from the AHA
database using the GWTG on adults
and children
• BMJ 5/2014 Donnino, Michael et al . They
studied 120,000 in patient PEA and Asystole
cardiac arrests to examine the question of timing
in administering epinephrine. What they found
was that if given at 1 minute 12 % survival was
seen and if given at 7 minutes there was only a
7% survival. Neurologically the patients who got
the drug early did much better neurologically.
There was a 10-20 % decrease in survival for
every 3 minutes in administration of epi. YOU
MUST GIVE IT EARLY.

12. Pediatric nonshockable arrests and
Epinephrine
• In JAMA August 2015, 1 month ago by Lars
Anderson [really !] et al . They had 1558
patients and again the time to epinephrine
was critical. If the time to epi was >5 minutes
the survival to discharge was 21 %. If the epi
was given in <5 minutes the survival to
discharge was 33%. There was a stepwise
decrease in survival, neurological outcome for
delays in administration of epinephrine just as
was seen in adults. GIVE IT EARLY

13. Capnometry
• CO2 is an odorless, colorless gas . It is created
as a byproduct of metabolism.
• A normal End Tidal CO2 is 35-45 mm.
• Levels >45 reflect hypoventilation, the patient
is not breathing well. They are retaining CO2
• Levels <35 are a result of hyperventilation

14. Capnometry
• There are 2 configurations of capnometry :
sidestream [a sample is diverted to the side]
and mainstream [a sample is measured at the
end and not diverted] . The mainstream is
used for intubated patients. The sidestream
may be used in any patient.

15. Capnometry
• Two recent cases are useful to look at the
multitude of ways that capnometry has
changed our practice

16. ETCO2 versus Oximetry
• ETCO2 reflects ventilation. CO@ rapidly diffuses
across cell membranes and if the airway is
compromised [not breathing, obstructed etc] the
ETCO2 will rapidly rise within seconds
• The oximetry will often remain artificially high for
minutes in these situations.
• Hold your breath for 2 minutes and watch as
your ETCO2 will rise quickly. The O2 sat will
hardly change
• This is the critical reason why ETCO2 must be
followed in patients receiving benzodiazepines or
narcotics. Imagine that this patient is placed on
oxygen at the same time . The O2 sat will not go
down for a long time after the ETCO2 has risen
[to reflect that the patient has ceased breathing]

17. ETCO2 vs Capnometry Cont’d
• In one study of intubated prehospital patients an
abnormal CO2 was documented BEFORE changes
in the O2 sat level in 70 % of patients with
hypoventilation.
• If the ET tube is dislodged the capnography
waveform will be markedly altered.
• In one study of paramedic intubation the groups
that used ETCO2 continuously had 0% misplaced
tubes. In those medics who did not use
capnography 23 % had misplaced the tube.

18. Cardiac Arrest and Capnography
• Capnography indirectly measures cardiac output . It is a
very good tool for measuring the effectiveness of CPR.
A capnography that remains less than 10 during a
resuscitation indicates futility . There has not been any
meaningful cardiac output. A sudden rise in ETCO2 will
frequently precede ROSC.
• So there are 2 good reasons to use Capnography in
arrests. It indicates that the tube is correctly placed
and has not been dislodged and it is the only effective
tool for measuring the effectiveness of our efforts with
CPR.

19. Capnometry continued
• The next few slides are all demonstrating
waveforms and their possible uses for
diagnosis. The waveforms are taken from a
monograph from Zoll.

25. USE OF ETCO2
In addition to cardiac arrest patients and patients
who are sedated other patients who must have
ETCO2 include :
Altered mental status , both to be certain they are
not retaining CO2 and to monitor their ventilation
status
Serious Head injury
All respiratory problems: asthma, COPD,CHF, etc

26. Institute of Medicine Report on
Cardiac Arrest
• The Institute of Medicine released a report this past
summer which describes cardiac arrest as the biggest
public health issue in the US. They noted the tremendous
variation in resuscitation rates in the US . They asked all of
us to try to commit our communities to try to increase
resuscitation rates. We need to do all of the things we are
trying to do. Every student should be trained in
CPR[preferably hands only] . They recommend community
wide programs to increase the number of lay rescuers,
programs to increase AED use and availability. They want all
programs to know their rates and to try t increase them. Its
all the things we are trying to do. Dispatch is a key
component . The report is over 400 pages long.

27. CVA Recognition
• CVA was only recognized in 50 % of the
patients in a recent study from NYC a total of
310 CVA patients]. The use of the CVA scale
was the single best predictor of success in
recognition . It was most commonly missed in
patients without motor findings and in
patients with severe strokes.
• In patients who had a CVA scale performed
the sensitivity was 84 % .

28. Cases
• The good x 3, the bad x 5 and the ugly x 4.